Heart Surgery Outcomes During COVID Similarly Worrisome for Rich and Poor Patients

SAN DIEGO — Cardiac surgery during the COVID-19 pandemic was associated with higher cost and worse survival regardless of one’s socioeconomic status, according to data from Virginia.

From a registry capturing virtually all adult cardiac surgeries in the region, researchers found that cases during the pandemic were significantly associated with large increases in risk-adjusted mortality (OR 1.398, 95% CI 1.179-1.657), cost (+$4,823, P<0.001), and failure to rescue (OR 1.37, 95% CI 1.10-1.70).

Surprisingly, there was no statistically significant effect modification by the patient’s assigned Distressed Communities Index — a measure of socioeconomic well-being at the level of the patient’s home zip code — according to Raymond Strobel, MD, MSc, a cardiothoracic surgery resident at the University of Virginia in Charlottesville.

Strobel presented his group’s work at the annual meeting of the Society of Thoracic Surgeons (STS). The study was also published in the Annals of Thoracic Surgery.

“Put succinctly, regardless of socioeconomic status during the pandemic, your postoperative outcomes were negatively influenced in a similar way whether you were from a more affluent or less affluent community,” he said.

This appears to contradict previous reports that had linked socioeconomic distress to poor outcomes after cardiac surgery.

However, since the pandemic, people who were able to undergo heart surgery in Virginia tended to be less socioeconomically distressed and at lower operative risk than before, Strobel and colleagues found, suggesting that the more vulnerable patients had trouble getting access to care such as cardiology appointments or bookings for surgery.

“It speaks to the need for programs that provide social services such as transportation and access to a physician,” Strobel told the audience at STS.

“Given the increase in postoperative failure to rescue and mortality and decrease in patients from distressed communities seen during the COVID-19 pandemic, there clearly exists a need for evidence-based cardiac surgery protocols for resource-constrained settings, and particularly, infectious disease outbreaks,” Strobel and colleagues wrote.

Session discussant Daniel Engelman, MD, of Baystate Medical Center in Springfield, Massachusetts, suggested potential roles of implicit or explicit provider bias on top of structural socioeconomic constraints.

Another dimension of the present study is its addition to the literature on COVID-19’s ill effects on health systems and support of prior observations of reduced cardiac surgery volumes and excess observed-to-expected 30-day mortality. Poor outcomes during the pandemic are thought to be related to delayed presentation of patients, hospital staffing difficulties, bed capacity constraints, and shortages of critical medications.

During the session’s Q&A, congenital heart surgeon Charles Fraser Jr., MD, of Dell Medical School at the University of Texas at Austin, noted the problem of nurse staffing, including the reliance on traveling nurses, as central to some of the observed effects of the pandemic.

“I completely agree,” said Strobel.

The good news is things may be improving. While operative mortality is still relatively high, failure to rescue in the late pandemic era has dropped back down to prepandemic levels, Strobel said. “Health systems are starting to catch up and improve staffing levels.”

For the study, Strobel and colleagues relied on the Virginia Cardiac Services Quality Initiative (VCSQI) and included 37,769 patients from 17 centers.

Surgeries from July 2011 and May 2022 were included. Nearly 20% of the study cohort underwent cardiac surgery after the onset of the COVID-19 pandemic, defined as March 13, 2020.

Strobel emphasized his group’s inclusion of hospital as a random effect to account for center-level clustering in the modeling.

The study nevertheless remained subject to potential unmeasured confounding due to its retrospective, observational design. What’s more, the VCSQI data may not be generalizable outside Virginia, and may underestimate the impact of COVID-19 due to the registry’s inability to capture patients who did not undergo cardiac surgery in the first place.